Individual
MRS. LORI A STACKOW
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PAC
Contact information
Practice address
1541 KINGS HWY, SHREVEPORT, LA 71103-4228
(318) 626-0000
(318) 629-4833
Mailing address
1512 W KIRBY PL, SHREVEPORT, LA 71103-3822
(318) 626-0177
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
332160
LA
363A00000X
Physician Assistant
PA10687
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010017182
REGENCE BS OF ID
ID
05
—
004385800
—
ID
05
—
153449704
—
TX
01
—
49008
DEPT OF LABOR AND INDUSTR
WA
01
—
601417200
DEEIOC
—
05
—
8434896
—
WA
01
—
PAJB6
BLUE CROSS OF ID
ID
Enumeration date
09/30/2005
Last updated
02/22/2023
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